2022 HIPAA/Billing

1

Patient name:* This field is required.if multiple patients from your family are seen at the office, please complete one for each patient.

First Name

Last Name

2

Check one* This field is required.

I have received the HIPAA 2022 paperwork.

Please email me the HIPAA 2022 paperwork.

3

Payments:* This field is required.

I am aware that my deductible may be starting over for the calendar year.

I have new insurance.

Insurance has stayed the same.

I am not using insurance.

4

My billing preference (please check one):* This field is required.

I agree to have the card on file charged around the 15th of each month.

Please email me a bill and I will pay within one week. (If I don't pay within one week, I agree to have the balance placed on the card on file).

Please mail me a bill and I will pay within one week. (If I don't pay within one week, I agree to have the balance placed on the card on file).

I need an alternative payment plan.

5

Upload photos of front & back of NEW insurance card (if applicable):

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

6

Insurance card holder's date of birth (if uploading new card):

Date

7

I have new credit card information I need added to my file:* This field is required.If yes, we will contact you to obtain the information.

YESNO

8

Please sign your name:* This field is required.

Clear

9

Relation to patient:* This field is required.

10

Today's date* This field is required.

Date